Dear Stupendous Students 4,

Myself and Mark McGraw, Director of New Bedford EMS
and one of my "expert" consultants on intubation. 

How do you feel about intubation? Do you think it’s important? Is it one of those skills that can be taught, or does it have to be practiced to be learned? Why do so many practitioners fail at intubation? Before we can answer those questions, lets talk about who is required intubate. Paramedics? Yes, all of them. Nurses? Only some of them. Doctors? Only some of them. Stew on that.

So every Paramedic can intubate, and we learn to intubate during our relatively short approximate 2 year training. Anesthesiologists train for over a decade. Certified Registered Nurse Anesthetists train for close to a decade. Does Captain Obvious need to make a sudden appearance to point out which way I’m going with this? Treat intubation like the privileged skill that it is, and do it right every time. My Paramedic Instructor used to always say, “There’s no excuse for a bad tube.” He didn’t mean you will never intubate the esophagus, he meant have the proficiency to recognize and reverse an esophageal intubation immediately, and the professional responsibility to check tube placement efficiently and frequently. He s right. There is NO ever-loving excuse for a bad tube. There is no pothole, patient movement, or “someone else’s,” fault for walking into the ED with a misplaced ETT. This is precisely the reason we have stethoscopes, capnography, end tidal Co2 caps, esophageal detector devices, visualization, condensation....etc! I mean really, with all of these tools at our disposal to check placement, IS there any excuse for a bad tube? 

For this blog, I sent out a survey to a select few Paramedics I know, that I would consider “experts” in the skill of intubation. It is interesting to see that 4 of the 5 answered the same exact to some of the questions. The fifth didn’t answer any at all and only said “Read Dr. Bledsoe’s articles on ‘The Disappearing Endotracheal Tube.” The questions were as follows, and the answers are summed up by me from the 4 that offered their advice. 

Q: What blade do you prefer and why?

A: Unanimously every medic preferred the Macintosh 4. All surveyors agree it has the versatility to give or take away “blade room” with more or less fingers applied to the base, alternately making it a Mac 3. It was also noted to easily lift the epiglottis when necessary, easily displace the tongue when necessary, give a “light” touch to a more delicate airway, and be used a straight or curved blade. Stellar advice to this question: “Don’t get married to a blade, folks. Anatomy differs and that’s why there are so many blades.” 

Q: Tips for holding the laryngoscope?

A: The majority agreed to hold the blade close to the handle next to the hinge, or at the bottom of the blade in the palm of your hand. One described it as placing your baby finger off the handle and under the blade to “choke up,” on the handle and get better control of the blade, lessening the tendency to lever back on the handle. Stellar advice to this question: “Hold it firm and keep your wrist locked. When you lift, go up and out. Pretend you’re aiming the handle at the intersection where the wall meets the ceiling. Not up, not forward, but right in the middle.” 

Q: Tips for identifying landmarks/cords?

A: Most agree it is most important to recognize anatomy, look at lots of pictures, and realize people have different anatomy that is not always text book looking. One very experienced Paramedic says “Don’t crawl into the patient’s mouth-get back from the patient to improve your visual perspective.” That line of thinking gives perspective to the “difficult tube” scenario because how often do we want to take a closer peep at that which we don’t understand, such as the mucous/blood filled airway?! In other words, step off! Check it out from a distance. Stellar advice to this question: “Know your cuneiform and corniculate cartilages ; where they are, what they look like and where they are in relation to the vocal cords. It helps greatly to recognize them especially with a deep, anterior patient. If you can identify them then you know the cords are above.”

Q: If you had to summarize successful intubation into one sentence, what would it be?

A: Everyone agrees that preparation and positioning are 2 of the most important considerations for consistent success. Here are the 4 sentences: 

1. It is imperative to be 100 percent familiar with the anatomy, don't play with it and move purposefully, watch the tube pass the cords, don't let go of the tube until its secure and recheck often.

2. Pre-planning, help, pre-positioning, insertion, confirmation, and affixing.

3. Successful intubation is the ability to manipulate the airway with a laryngoscope, visualize the cords, place an ET through, inflate, secure and confirm.

4. Set your patient up for success, positioning is the key. 

Q: Other advice/wisdoms/experiences?

A:  All 4 agree that intubation is a true skill that requires plenty of practice. It is one of the most important skills we perform and should be mastered. Line up ears to sternum for difficult intubations and create a ramp like towel or blanket roll to prop the shoulders up. In the absence of C-spine precautions, don’t be afraid to manipulate the head, flexing and extending while visualizing with the laryngoscope and noting how the different movements open and close the airway. Always use a stylet! Most patients with an anterior airway are usually deviated to the left. Stellar advice to this question: “Take 10 sec and set your patient up for success!!!”   

I’m so glad I sent out that survey, and thank you very much to the medics who answered. You guys are so awesome your middle initials are A, you should work for Awesome EMS, people should address you as “your awesomeness,” your cell phone carriers should be Awesome T&T and you should talk on an A-phone, you should have your own TV Network called “The Awesome Channel” that features only shows about how awesome you are, and you should all have a talking mirror that says “you look Awesome today,” every time you look in it! 

It was interesting to see the same advice being repeated consistently among the 4, especially know your anatomy, prepare yourself and your patient for intubation, prop the shoulders, hold the blade with your hand near the hinges, and check and recheck your tube! For the students who ride at NBEMS: The airway bag on all of our trucks is in an outside compartment on the drivers side of the ambulance. That means the driver almost always carries that bag. For that reason, oftentimes it is the driver who intubates, although some medics prefer to intubate their own patient since they will ultimately be responsible for transferring and documenting the tube. Familiarize yourself with the location and contents of this bag, possibly even feel out the crew for what their preferences are when it comes time to intubate. Don’t wait until you’re smack in the middle of a cluster to fumble around for equipment or permission! 

I hope this blog has made you recognize the importance of mastering this very difficult skill. Study airway anatomy repetitiously! Go back to the classroom and practice. Talk to other Paramedics, Nurses, Doctors, Respiratory Therapists and anyone else that intubates about their successes...and failures. NEVER deliver a bad tube. Stellar advice on this subject:

“Think before acting; it is better to come in with no tube than a bad tube...” 

Dear Stupendous Students 3,

It’s the moment you’ve been waiting for! That time of the blog when we talk about your two favorite things: Intubation and starting I.V.’s! I’ve pondered: why do Paramedic Students, and Paramedics, for that matter, have such a doting infatuation with these two skills? Sure, doing them, and especially doing them well is important but are they really worth writing home about? The best thing I can come with is these two skills are a couple of things that really separate Medics from Basics, Nurses, and other related health care providers, and elevate the practice. In this way our anxious, desperate little egos are sated and stroked with all the vigor of the overweight birthday boy eating cake!  

Because IV Chapters in most texts have to focus on more than just venipuncture, and the fact that its a skill that requires hands on practice, I see alot of students struggling. Mostly they make the same common mistakes, which are easy to correct. Over the years, I’ve developed some reliable tactics that have made a better puncture-er out of me, and will make a better puncture-er out of you! First, I’m going to challenge some of those narrow, tunnel visioned little minds out there with my IV philosophies: 

HEINOUS and BOGUS I.V. MYTH #1: “Go Big, or Go Home.”  When I hear the utterance of this faulty logic, my blood boils redder than the words they are typed in. I hear the distant wail of a cargo barge’s horn, and I have to block my ears so the steam doesn’t scald the person standing near me! That is the single most ignorant, uneducated, egotistical, pathetic, my-life-is-so-worthless-and-my-self-esteem-is-lower-than-a-dead-persons-blood-pressure-but-I-try-to-be-cool-to-impress-people *deep, cleansing breath,* declaration I could possibly hear someone say. The fact of the matter is, introducing intravenous catheters into the different arms, and different skin, and different vasculature, and different circumstances of different people (noting the pattern, here?) requires skill that goes beyond plucking the green package from the I.V. tray. Yes, I said it, in case you only inferred: Professionals who choose to blindly start large bore I.V.’s with no indication of necessity are weak, mindless robots who lack the skill to adapt to the situation at hand (no pun intended, lol).  For precisely the reason there is different sized catheters, there are different sized situations that justify them. 

A “shock trauma” pt with a significant mechanism and a pressure in the toilet, large bore I.V.? YES! 

A 90 year old female that weighs 85 lbs and has a tummy ache, and her arthritis is acting up, and she hasn’t moved her bowels in 3 hours, and....large bore I.V.? NEGATIVE. 

A 56 year old male, pale and diophoretic with persistent chest pain after fixing that gutter his wife has been nagging him about, radiating down his L arm, unrelieved post NTG, with ST elevations on the 12 lead, large bore I.V.? IF YOU CAN, 2 of ‘em, EN ROUTE and transport to a cath lab. If you can only get 1-2 20g, that is fine, you have lots more to worry about with this patient than sticking in an 18g, and a 20g works JUST AS WELL.

A 24 year old female with chronic abdominal pain d/t intestinal HAE requesting pain control (out of Percocets), otherwise in stable condition in no obvious distress, large bore I.V.? SERIOUSLY? Do you have to do it just because you can? Will you go big or go home? I would rather see you go home. Blood transfusions, fluid resuscitation,  and CT dye can all be infused just as easily through a #20 as they can a #18. Bottom Line: It is BARBARIC to use large bore I.V.’s outside of necessity, just because you can, especially in the hand. Get over yourself.

HEINOUS and BOGUS I.V. MYTH #2: “They pissed me off, so they got a 16 in the hand.” Ok, Romper Room is closed for today, come back in 9,742,886 hours after you grow up! I understand why some people say this, it’s to just to let off a little steam and vent a bit. I’m all about that, hey this is a tough job, right? It’s the folks out there who actually do it and brag about it that make me want to cannulate their sclera veins. Which I would do, because they “piss me off.” Haha, kidding! Seriously, students and medics: If you think saying or doing this makes you look ultra snazzy and powerful, it doesn’t. It is a naive and weak way to practice, even when you’re mad because American Idol just got interrupted to haul around the obtunded ETOH illegal citizen. Get over yourself. 

HEINOUS and BOGUS I.V. MYTH #3: “Well, they were gonna do it the hospital, probably.” This statement can go both ways, it can actually be applicable, or it can indicate Cookbook medic practice. What I want to emphasize is: Do it because you feel it’s appropriate, not because you know someone else will. Own your decisions, skills, and actions. Outside of gross incompetence or assault, I can’t think of many circumstances where starting an I.V. would be negligent, but I still want to encourage students to start developing confidence in their own assessments, interventions, and decisions. Get into yourself! 

Let me state clearly, I am not trying to bash my fellow medics, or single out any one person. I know plenty of Paramedics who I think are super fabulous, that I have learned alot from, who I have known to advocate one or more of these philosophies. Maybe they learned from their mentors, or maybe they have other arguments to support their convictions. These are solely the opinions of my own shattered, pea-brained little mind! ☺ 

Starting from the Top: 

1. Do a Skin Assessment: Does it look/feel papery thin? Use less pressure puncturing the skin. Does it look/feel thick and coarse, and the pt. tells you they are a construction worker, or someone who stays out in the elements alot? Use more pressure puncturing the skin. Is the pt. on coumadin/lovenox/other “blood thinners”? Be wary of the increased risk for bleeding/infiltration/hematoma. Is the pt. on Prednisone? Even a small gauge needle will obliterate the vein, it will look like subdermal vein implosion, be wicked careful! Is the pt. hyperglycemic? If so, their veins can be hardened and very difficult to cannulate. Think of it like this: high blood sugar=candy-coated veins. Doing a thorough skin assessment takes about 10 seconds, and will dramatically increase your I.V. success rate. 
2. Get Gabby: Nothing makes a patient, or any human for that matter, more uncomfortable than a muted caregiver performing foreign and painful procedures on them while they’re in pain, distress, or discomfort. If you’re feeling kind of nervous and awkward being a student with 2 or more medics, firefighters, and police officers watching and judging your actions, can you imagine how intimidated the patient feels with all of these unfamiliar people, plus the addition of painful or misunderstood interventions?! Use your voice: explain what you’re doing, talk about their complaint, give some feed back, use humor, etc...the more at ease you appear, the more at ease they will feel and trust me, you will get more thanks and acknowledgment for simply making someone feel comfortable than you will for “saving their life.” 
3. Applying the Tourniquet: I’ve found that applying the tourniquet about 4-5 inches above the elbow is the most practical and effective practice. It effectively engorges the veins from the distal end of the arm to above the AC. It also prevents unnecessary relocation of the tourniquet after unsuccessful attempts or poor vasculature. Also, that tight tourniquet hurts! If possible, tie it over the sleeve. A tip on using a blood pressure cuff as a tourniquet: I don’t advocate this as a rule, but it works in a pinch. Apply the cuff around the upper arm like you normally would, and pump it up slowly to about 40 mmHg or until veins are distended. Do not inflate it completely as it will cause pain and possibly bruising, and become an arterial tourniquet restricting blood flow to the whole arm. Also for veins that just refuse to appear, a second tourniquet placed distal to the initial tourniquet but proximal to the area you will be scouting works well. 
4. Get Prepared: Gather all of the equipment you expect to need for this I.V. start, including 2x2’s, tape, even the glucometer if you routinely check CBG’s with the sharps. Set up and prime the lock set, or drip set or whatever you use to flush the line. Open the alcohol prep, betadine swab, bioclusive dressing and whatever else you use, except the angio cath (for sterility). I cannot stress enough how this simple act of gathering, preparing, and placing your equipment next to you will help your success. It also gives that tourniquet time to work, and keeps you focused and organized. 
5. Find a Vein: Here is the single best I.V. tip I can offer, but it won’t help a lick in your internship: Learn how to feel the vein. Palpate it with the pads of your fingers. My absolute golden nugget of wisdom is to train one hand to have your palp fingertips. I use my non-dominant hand, so my L hand can feel a vein decades before my eyes can even see it. Start practicing with your “tactile vein hand,” on EVERY I.V. start, even when a vein is standing up and getting its flirt on, to get used the feel of them. It is described as “spongy,” “springy,” or that it “gives” under pressure. To me, they feel like little tubes of moon bounce material, and I visualize what the distended, engorged vein looks like underneath the skin. It won’t take long before your palp hand is heavy, and “this pt. has NO VEINS, dude,” will be a thing of the past. 
6. Prepare the Vein: Veins need love, too. Please do not forcefully slap, spank, thump, or flick them. Flattened veins may need a little help perking up, and I agree it is acceptable to use the pads of 2 or 3 fingers and tap to plump them a bit, but roundhouse kicking them in the face is not acceptable. Hanging the arm down and employing dependent gravity, having the pt. pump their fist, even using a few extra alcohol preps and rubbing briskly over the site (get some friction heat going) are all options to get that vein really engorged. Use care and discretion when applying brute force to a vein, and remember: it hurts!
7. Feel that Strrrrretchhhhh: The second most valuable tip I can offer is a simple one: Hold the skin taut! Whether you’re initiating in the hand, forearm, AC, or foot this rule applies:  Apply enough counter tension to the skin to anchor the vein, and set up a smooth surface for the needle to pierce through the skin. This is the most common mistake I see students make! HOLD THE SKIN TAUT. Be sure not to press into the vein causing it to occlude and collapse, just pull the skin with enough tension to anchor the tissue and vein underneath it. 
8. Venipuncture: Telling a patient “Ok, it’s going to be a biiig stick,” is the equivalent of telling the drivers seat “Ok, here comes my biiig butt!” Make it understandable or at least relatable, “This is going to feel like a pinch on your arm,” or “It’s going to sting/hurt for just a sec,” etc...just don’t say it’s going to be a “big stick.” A big stick comes from a tree limb, and if you go after a patient with one, you’ll have more to worry about then the semantics of your I.V. starts! On holding the angio cath: Familiarize yourself with the equipment you’re using. Too often I see students who are not holding the equipment properly, and we carry the same I.V.s as St. Luke’s where I just saw them for weeks doing hospital internship?! I don’t get it, but I am more than happy to happy to demonstrate and explain how to use the equipment I carry. Simply put: Bevel up, which coordinates nicely with the little tab sticking up near the top of the colored catheter hub. KEEP YOUR FINGER ON THAT TAB AT ALL TIMES, until it’s time to advance the catheter. 
9. Stay Focused: The rest is home plate material, but stay focused! At NBEMS we routinely use I.V. sharps to check CBG so don’t lose it, throw it on the floor, or get something all bloody with it. Hand to one of us, or set it near the glucometer. If possible, clean up after yourself!  Staying focused and following simple actions through to the end trains your mind to do so on auto pilot, even on the more complex actions, such as intubating. If you’re always cognizant of where you place the laryngoscope after ET placement, you won’t lose, cross contaminate, or damage it. Stay focused, and follow all tasks through to completion. 
10. I pick things up, I put them down: Or, in this case I put things in your vein, I take them back out. With the exception of discontinuing an unsuccessful or “blown” line, in the field we don’t pull too many I.V. catheters, but it’s still worth saying: When you do remove a catheter, apply pressure with the 2x2 directly after the catheter is out, not during the removal. If you apply pressure while removing the cath you risk complete transection of an already sheared catheter (causing a foreign body embolism, yikes!), and for a long dwelling cath, you basically squeegee off all of that biological goo clinging to the catheter and expel it into the pt. Eww! Plus, it plain old hurts more to apply pressure while pulling the line, so don’t do it!

Read, study, print these tips, if you like! I guarantee they will make a better “sticker” out of you! These tips are designed to enhance your skill, not teach it! Now, get out there and make me proud, EMT-Paramedic Interns! Tune in next week for my Intubation tips and tricks and blog!